A listener, Brian Katan, wrote to suggest adding ondansetron to the awake intubation procedure. Now this is interesting, because I don't want the patient to vomit from ramming things into the back of her throat, but the mechanism is not nausea–it is the gag reflex. So, the question is: does ondansetron affect the gag reflex? Turns out it does…
Evaluation of the efficacy of oral ondansetron on gag reflex in soft palate and palatine tonsil areas
So now, ondansetron 4 mg IVP has been added to the airway checklist. Thanks Brian!
Scott Weingart
An ED Intensivist from NY. No conflicts of interest (coi).
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[…] is also an interesting article on the EMCrit Blog suggesting that ondanstron suppresses the gag reflex and may be useful in awake […]
IV Granisteron has also been looked at (successfully, though small groups but blinded and placebo control)
I used to use it for this reason (when it was still in our cupboards) for ENT lists; have since switched to Ondansetron
Never occured to me to use it in AFO intubation as well though; good tip!
-John
I routinely use it for any procedural sedation
OK, interesting information. I just administered Ondansetron 4 mg IVP to my patient I am sedating just now. Some 15 years ago, I was privy to an unusual side effect of Ondansetron in a patient I cared for that underwent anterior cervical discectomy and fusion. He was a tall, thin gentleman in his early 40’s with a history of herniated cervical discs. Surgical procedure, airway management and anesthetic was unremarkable, and I was making a brief visit to the patient the afternoon of postop day 1 when the story gets interesting. The patient was recovering well, and had just returned from physical therapy when I paid him a visit postop day 1. He was otherwise without complaint, save for feeling nauseated. I reassured him, ordered Ondansetron 4 mg IV for nausea, and took my leave for the doctors’ locker room to change out of scrubs and leave the hospital. As I was exiting the hospital, a cardio-pulmonary arrest alert was called over the hospital PA system to that patient’s room. I ran up to assist with the crisis, and found the patient receiving bag-valve-mask ventilation from a respiratory therapist, patient visibly awake, with eyes wide open in terror. I slid… Read more »
Crazy stuff, ours come in little bags that have to drip in. Good to know.
I never, ever, ever just walk up to an IV and jam the medication in unless it is clearly indicated, i.e. adenosine challenge or RSI procedure. I teach and stress the need to dilute and administer slowly most medications as we give it. Working in the ED, I hang a bag of NS after I start most of my IV’s to ensure the pain and nasea medications are given with a little dilution to avoid deleterious effects. Thoughts.
Can I get an Amen? Amen!
Amen!
Sounds good to me. You never want full drug in 1st pass except for the situations you mentioned.
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